Program Operations Manual System (POMS)

A. What skin disorders do we evaluate with these listings

We use these listings to evaluate skin disorders that may result from hereditary,
congenital, or acquired pathological processes. The kinds of impairments covered by
these listings are: Ichthyosis, bullous diseases, chronic infections of the skin or
mucous membranes, dermatitis, hidradenitis suppurativa, genetic photosensitivity disorders,
and burns.

B. What documentation do we need?

When we evaluate the existence and severity of your skin disorder, we generally need
information about the onset, duration, frequency of flare ups, and prognosis of your
skin disorder; the location, size, and appearance of lesions; and, when applicable,
history of exposure to toxins, allergens, or irritants, familial incidence, seasonal
variation, stress factors, and your ability to function outside of a highly protective
environment. To confirm the diagnosis, we may need laboratory findings (for example,
results of a biopsy obtained independently of Social Security disability evaluation
or blood tests) or evidence from other medically acceptable methods consistent with
the prevailing state of medical knowledge and clinical practice.

C. How do we assess the severity of your skin disorder(s)?

We generally base our assessment of severity on the extent of your skin lesions, the
frequency of flare ups of your skin lesions, how your symptoms (including pain) limit
you, the extent of your treatment, and how your treatment affects you.

1. Extensive skin lesions. Extensive skin lesions are those that involve multiple body sites or critical body
areas, and result in a very serious limitation. Examples of extensive skin lesions
that result in a very serious limitation include but are not limited to:

a. Skin lesions that interfere with the motion of your joints and that very seriously
limit your use of more than one extremity; that is, two upper extremities, two lower
extremities, or one upper and one lower extremity.

b. Skin lesions on the palms of both hands that very seriously limit your ability
to do fine and gross motor movements.

c. Skin lesions on the soles of both feet, the perineum, or both inguinal areas that
very seriously limit your ability to ambulate.

2. Frequency of flare ups. If you have skin lesions, but they do not meet the requirements of any of the listings
in this body system, you may still have an impairment that prevents you from doing
any gainful activity when we consider your condition over time, especially if your
flare ups result in extensive skin lesions, as defined in DI 34128.007C.1. in this section. Therefore, if you have frequent flare ups, we may find that your
impairment(s) is medically equal to one of these listings even though you have some
periods during which your condition is in remission. We will consider how frequent
and serious your flare ups are, how quickly they resolve, and how you function between
flare ups to determine whether you have been unable to do any gainful activity for
a continuous period of at least 12 months or can be expected to be unable to do any
gainful activity for a continuous period of at least 12 months. We will also consider
the frequency of your flare ups when we determine whether you have a severe impairment
and when we need to assess your residual functional capacity.

3. Symptoms (including pain). Symptoms (including pain) may be important factors contributing to the severity
of your skin disorder(s). We assess the impact of symptoms as explained in §§ 404.1528,
404.1529, 416.928, and 416.929 of this chapter.

4. Treatment. We assess the effects of medication, therapy, surgery, and any other form of treatment
you receive when we determine the severity and duration of your impairment(s). Skin
disorders frequently respond to treatment; however, response to treatment can vary
widely, with some impairments becoming resistant to treatment. Some treatments can
have side effects that can in themselves result in limitations.

a. We assess the effects of continuing treatment as prescribed by determining if there
is improvement in the symptoms, signs, and laboratory findings of your disorder, and
if you experience side effects that result in functional limitations. To assess the
effects of your treatment, we may need information about:

i. The treatment you have been prescribed (for example, the type, dosage, method,
and frequency of administration of medication or therapy);

ii. Your response to the treatment;

iii. Any adverse effects of the treatment; and

iv. The expected duration of the treatment.

b. Because treatment itself or the effects of treatment may be temporary, in most
cases sufficient time must elapse to allow us to evaluate the impact and expected
duration of treatment and its side effects. Except under 8.07 and 8.08, you must follow
continuing treatment as prescribed for at least 3 months before your impairment can
be determined to meet the requirements of a skin disorder listing. (If you are not
undergoing treatment or did not have treatment for 3 months, see 8.00H.) We consider
your specific response to treatment when we evaluate the overall severity of your
impairment.

D. How do we assess impairments that may affect the skin and other body systems?

When your impairment affects your skin and has effects in other body systems, we first
evaluate the predominant feature of your impairment under the appropriate body system.
Examples include, but are not limited to the following:

1. Tuberous sclerosis primarily affects the brain. The predominant features are seizures, which we evaluate
under the neurological listings in 11.00, and developmental delays or other mental
disorders, which we evaluate under the mental disorders listings in 12.00.

2. Malignant tumors of the skin (for example, malignant melanomas) are cancers, or neoplastic diseases, which we
evaluate under the listings in 13.00.

3. Connective tissue disorders and other immune system disorders (for example, systemic lupus erythematosus, scleroderma, human immunodeficiency virus
(HIV) infection, and Sjögren’s syndrome) often involve more than one body system.
We first evaluate these disorders under the immune system listings in 14.00. We evaluate
lupus erythematosus under 14.02, scleroderma under 14.04, symptomatic HIV infection
under 14.08, and Sjögren’s syndrome under 14.03, 14.09, or any other appropriate listing
in section 14.00.

4. Disfigurement or deformity resulting from skin lesions may result in loss of sight, hearing, speech, and the
ability to chew (mastication). We evaluate these impairments and their effects under
the special senses and speech listings in 2.00 and the digestive system listings in
5.00. Facial disfigurement or other physical deformities may also have effects we
evaluate under the mental disorders listings in 12.00, such as when they affect mood
or social functioning.

E. How do we evaluate genetic photosensitivity disorders

1. Xeroderma pigmentosum (XP). When you have XP, your impairment meets the requirements of 8.07A if you have clinical
and laboratory findings showing that you have the disorder. (See 8.00E.3.) People
who have XP have a lifelong hypersensitivity to all forms of ultraviolet light and
generally lead extremely restricted lives in highly protective environments in order
to prevent skin cancers from developing. Some people with XP also experience problems
with their eyes, neurological problems, mental disorders, and problems in other body
systems.

2. Other genetic photosensitivity disorders. Other genetic photosensitivity disorders may vary in their effects on different
people, and may not result in an inability to engage in any gainful activity for a
continuous period of at least 12 months. Therefore, if you have a genetic photosensitivity
disorder other than XP (established by clinical and laboratory findings as described
in 8.00E.3.), you must show that you have either extensive skin lesions or an inability
to function outside of a highly protective environment to meet the requirements of
8.07B. You must also show that your impairment meets the duration requirement. By
inability to function outside of a highly protective environment we mean that you
must avoid exposure to ultraviolet light (including sunlight passing through windows
and light from unshielded fluorescent bulbs), wear protective clothing and eyeglasses,
and use opaque broad-spectrum sunscreens in order to avoid skin cancer or other serious
effects. Some genetic photosensitivity disorders can have very serious effects in
other body systems, especially special senses and speech (2.00), neurological (11.00),
mental (12.00), and neoplastic (13.00). We will evaluate the predominant feature of
your impairment under the appropriate body system, as explained in 8.00D.

3. Clinical and laboratory findings. We need evidence confirming the diagnosis of your XP or other genetic photosensitivity
disorder. The evidence must include a clinical description of abnormal physical findings
associated with the condition. There must also be definitive genetic laboratory studies
documenting appropriate chromosomal damage, abnormal DNA repair, or other DNA or genetic
abnormality specific to your type of photosensitivity disorder. However, we do not
need a copy of the actual laboratory report if we have medical evidence that is persuasive
that a positive diagnosis has been confirmed by laboratory testing.

F. How do we valuate burns?

Electrical, chemical, or thermal burns frequently affect other body systems; for example,
musculoskeletal, special senses and speech, respiratory, cardiovascular, renal, neurological,
or mental. Consequently, we evaluate burns the way we evaluate other disorders that
can affect the skin and other body systems, using the listing for the predominant
feature of your impairment. For example, if your soft tissue injuries are under continuing
surgical management (as defined in 1.00M), we will evaluate your impairment under
1.08. However, if your burns do not meet the requirements of 1.08 and you have extensive
skin lesions that result in a very serious limitation (as defined in 8.00C.1.) that
has lasted or can be expected to last for a continuous period of at least 12 months,
we will evaluate them under 8.08.

G. How do we determine if your skin disorder(s) will continue at a disabling level of
severity in order to meet the duration requirement?

For all of these skin disorder listings except 8.07 and 8.08, we will find that your
impairment meets the duration requirement if your skin disorder results in extensive
skin lesions that persist for at least 3 months despite continuing treatment as prescribed.
By persist, we mean that the longitudinal clinical record shows that, with few exceptions, your
lesions have been at the level of severity specified in the listing. For 8.07A, we
will presume that you meet the duration requirement. For 8.07B and 8.08, we will consider
all of the relevant medical and other information in your case record to determine
whether your skin disorder meets the duration requirement.

H. How do we assess your skin disorder(s) if your impairment does not meet the requirements
of one of these listings?

1. These listings are only examples of common skin disorders that we consider severe
enough to prevent you from engaging in any gainful activity. For most of these listings,
if you do not have continuing treatment as prescribed, if your treatment has not lasted
for at least 3 months, or if you do not have extensive skin lesions that have persisted
for at least 3 months, your impairment cannot meet the requirements of these skin
disorder listings. (This provision does not apply to 8.07 and 8.08.) However, we may
still find that you are disabled because your impairment(s) meets the requirements
of a listing in another body system or medically equals the severity of a listing.
(See §§ 404.1526 and 416.926 of this chapter.) We may also find you disabled at the
last step of the sequential evaluation process.

2. If you have not received ongoing treatment or do not have an ongoing relationship
with the medical community despite the existence of a severe impairment(s), or if
your skin lesions have not persisted for at least 3 months but you are undergoing
continuing treatment as prescribed, you may still have an impairment(s) that meets
a listing in another body system or that medically equals a listing. If you do not
have an impairment(s) that meets or medically equals a listing, we will assess your
residual functional capacity and proceed to the fourth and, if necessary, the fifth
step of the sequential evaluation process in §§ 404.1520 and 416.920 of this chapter.
When we decide whether you continue to be disabled, we use the rules in §§ 404.1594
and 416.994 of this chapter.